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Review Question - QID 109849

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QID 109849 (Type "109849" in App Search)
A 17-year-old girl is brought to her primary care physician by her parents. The parents state that their daughter is unruly and never listens. They think her hygiene has recently declined and the only friends she has are imaginary. The daughter is quiet and seems to have a depressed and withdrawn mood. The patient has a medical history of asthma that is treated with albuterol. Her temperature is 99.5°F (37.5°C), blood pressure is 90/48 mmHg, pulse is 80/min, respirations are 17/min, and oxygen saturation is 98% on room air. The patient's body mass index is 14.5 kg/m^2. Physical exam reveals a sad young woman. Cardiopulmonary exam is within normal limits. Abdominal exam reveals decreased bowel sounds and is non-tender in all quadrants. Dermatologic exam is notable for dry skin. Ophthalmologic exam is notable for the finding in Figure A. Lab values are ordered as seen below.

Hemoglobin: 11 g/dL
Hematocrit: 33%
Leukocyte count: 6,500/mm^3 with normal differential
Platelet count: 197,000/mm^3

Serum:
Na+: 139 mEq/L
Cl-: 100 mEq/L
K+: 4.0 mEq/L
HCO3-: 26 mEq/L
BUN: 20 mg/dL
Glucose: 62 mg/dL
Creatinine: 1.1 mg/dL
Ca2+: 9.0 mg/dL
AST: 12 U/L
ALT: 10 U/L

Which of the following is most likely deficient in this patient?
  • A

Folate

0%

0/53

Vitamin A

91%

48/53

Vitamin B12

4%

2/53

Vitamin D

0%

0/53

Vitamin E

6%

3/53

  • A

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This patient is presenting with dermatologic abnormalities and Bitot spots suggesting a diagnosis of vitamin A deficiency. This may be secondary to anorexia nervosa in this patient.

Vitamin A deficiency presents in malnourished patients (anorexic and bulimic) or states of fat malabsorption (inflammatory bowel disease and pancreatitis). Symptoms include loss of night vision, photophobia, dry skin, xerosis conjunctiva, xerosis cornea, keratomalacia, and Bitot spots. Long-term deficits from prolonged deficiency can include vision loss. Any underlying conditions should be treated, and vitamin A should be supplemented.

Song et al. review the evidence regarding the diagnosis of patients with vitamin A deficiency. They discuss how this condition can still exist even in well-resourced areas. They recommend early intervention with vitamin supplementation.

Figure/Illustration A is a clinical photograph that demonstrates a dry-appearing triangular patch of conjunctiva (red circle). These Bitot spots can be seen in vitamin A deficiency.

Incorrect Answers:
Answer 1: Folate deficiency would present with megaloblastic anemia but would not present with the ophthalmologic findings above. It is more common in alcoholics and malnourished patients. Treatment is with folate supplementation in the diet.

Answer 3: Vitamin B12 deficiency can present with megaloblastic anemia, peripheral neuropathy, and other neurological sequelae such as dementia. Treatment is with identifying the underlying cause of the deficiency and providing vitamin repletion.

Answer 4: Vitamin D deficiency can present with osteomalacia, depressed immune function, and in some cases depressed mood. Treatment is with vitamin D repletion or supplementation.

Answer 5: Vitamin E deficiency can present with posterior column degeneration (loss of proprioception) and hemolytic anemia. This condition is rare but can be treated with vitamin supplementation.

Bullet Summary:
Vitamin A deficiency presents with loss of night vision, photophobia, dry skin, xerosis conjunctiva, xerosis cornea, keratomalacia, and Bitot spots.

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